Provide me the serial report and diagnosis ?
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Now I have all the data. Let me also note what the handwritten referral note says from the image, then compile the full serial report and diagnosis.
The handwritten note reads:
- C/o imbalance, swaying while walking, gait issues at standing - 1 month
- Rotatory vertigo - twice
- Vomiting just once
Here is the complete Serial VNG Report and Diagnosis for Satish Bansal:
Videonystagmography (VNG) Report
Patient: Satish Bansal | ID: CCDA00377 | Age: 73 years | Gender: Male
Date of Test: 03-Jun-2026 | Clinic: Priority Hearing Care Pvt. Ltd.
Clinical History (from referral note)
- Imbalance and swaying while walking; gait issues on standing - 1 month duration
- Rotatory vertigo - 2 episodes
- Vomiting - 1 episode
Serial Report - Test-by-Test Findings
1. Saccades (Eye Movement Accuracy)
| Parameter | Right Eye | Left Eye | Normal Range |
|---|---|---|---|
| Horizontal Velocity | 500.47 °/s | 1066.99 °/s | ~300-700 °/s |
| Horizontal Precision | 82.22 | 134.83 | ~85-115 |
| Horizontal Latency | 247.50 ms | 274.29 ms | 150-250 ms |
| Vertical Velocity | 329.32 °/s | 382.61 °/s | ~200-500 °/s |
| Vertical Latency | 381.82 ms | 374.55 ms | 150-250 ms |
Findings: Left eye shows markedly elevated horizontal saccadic velocity (1066.99 °/s) with poor precision (134.83 - overshoot/hypermetria). Both eyes show mildly prolonged latencies. Abnormal - asymmetric saccadic performance suggestive of central or cerebellar involvement.
2. Smooth Pursuit
| Direction | Right Eye Gain | Left Eye Gain | Normal (>0.6) |
|---|---|---|---|
| Horizontal Rightward | 0.16 | 0.30 | ≥0.6 |
| Horizontal Leftward | 0.52 | 0.88 | ≥0.6 |
| Vertical Upward | 0.70 | 0.61 | ≥0.6 |
| Vertical Downward | 0.69 | 0.76 | ≥0.6 |
Findings: Horizontal smooth pursuit gain is significantly reduced bilaterally, especially rightward (0.16 RE, 0.30 LE). Vertical pursuit is relatively preserved. Abnormal - impaired horizontal smooth pursuit, consistent with central (cerebellar/brainstem) or age-related dysfunction.
3. Optokinetic Test (OKN)
| Direction | Right Eye Gain | Left Eye Gain |
|---|---|---|
| Left to Right | 0.84 | 0.67 |
| Right to Left | 1.08 | 1.13 |
| Top to Bottom | 0.99 | 1.58 |
| Bottom to Top | 1.10 | 0.76 |
Findings: OKN gains are asymmetric across directions. Left-eye gain is reduced for leftward and upward motion. Overall OKN is partially preserved but asymmetric. Mildly abnormal.
4. Spontaneous Nystagmus
| Condition | Finding |
|---|---|
| In Light | Absent (no nystagmus) - Normal |
| In Dark | Present - Slow phase velocity ~17 °/s (both eyes), frequency 2.38-2.57 Hz, fast phase direction ~157-169° (leftward/horizontal) |
Findings: Spontaneous nystagmus is absent in light (fixation suppresses it) but present in darkness with left-beating fast phase at ~17 °/s. This is a direction-fixed spontaneous nystagmus suppressed by visual fixation, strongly pointing to a peripheral vestibular lesion on the right side (Alexander's Law pattern).
5. Head Shake Nystagmus (HSN)
Findings: Post-head-shake nystagmus noted in the left eye (SPV -2.74 horizontal, -3.39 vertical). This indicates vestibular asymmetry, consistent with right-sided peripheral hypofunction.
6. Hyperventilation Test
Findings: No nystagmus provoked. Normal.
7. Gaze Tests
| Gaze Position | With Fixation | Without Fixation |
|---|---|---|
| Center | Mild left eye nystagmus (SPV ~5 °/s) | Nystagmus present - SPV 13-15 °/s bilateral |
| Left | No nystagmus | Nystagmus present - SPV 8-12 °/s |
| Up | Minimal residual | Nystagmus - SPV 19-20 °/s (most pronounced) |
| Right | No nystagmus | No nystagmus |
| Down | No nystagmus | No nystagmus |
Findings: Gaze nystagmus is absent or suppressed with fixation but emerges without fixation, predominantly in center, left, and up gaze. Absent in rightward and downward gaze. This direction-fixed (leftward-beating) gaze nystagmus is consistent with right peripheral vestibular hypofunction. No direction-changing gaze nystagmus (which would suggest central pathology).
8. Positional / Dix-Hallpike Tests
| Position | Finding |
|---|---|
| Dix-Hallpike Right - Supine Head Ext. & Right | Nystagmus present - SPV ~5-7 °/s both eyes, fast phase ~140°, freq ~1.7-1.87 Hz |
| Dix-Hallpike Right - Sit (return) | Residual low-amplitude nystagmus |
| Dix-Hallpike Left - Supine Head Ext. & Left | Nystagmus present - horizontal SPV ~5.6-5.74 °/s, freq ~1.01-1.82 Hz |
| Dix-Hallpike Left - Sit (return) | No nystagmus |
| Head Position Yaw Right | Nystagmus present - SPV ~6-6.86 °/s |
| Head Position Yaw Left | No nystagmus |
| Pitch Forward | Low-amplitude nystagmus |
| Pitch Backward | Nystagmus present - SPV ~5-8 °/s both eyes |
| Roll Right | Nystagmus present - SPV ~5-9 °/s |
| Roll Left | Mild residual nystagmus left eye only |
Findings: Positional nystagmus is triggered with the right Dix-Hallpike (supine with head extended and turned right), with direction approximately 140-141° (posterior-beating + torsional), consistent with right posterior semicircular canal BPPV. Nystagmus is also noted in several other head positions, suggesting possible multi-canal or cupulolithiasis variant.
9. Subjective Visual Vertical (SVV)
| Trial | Deviation | Direction |
|---|---|---|
| Clockwise test | +3° (Right tilt) | CW |
| Anti-clockwise test | -3° (Left tilt) | CW |
| Blank background | -1° (Left tilt) | CW |
Findings: SVV deviations are within the borderline range (normal ±2-3°). Consistent with possible mild right-sided otolithic (saccular/utricular) involvement, but not markedly abnormal.
Summary of Abnormal Findings
| Test | Finding | Significance |
|---|---|---|
| Saccades | Left eye hypermetria, prolonged latencies | Central/cerebellar component |
| Smooth Pursuit | Reduced horizontal gains bilaterally | Central or age-related |
| Spontaneous Nystagmus (dark) | Left-beating, ~17 °/s | Right peripheral hypofunction |
| Gaze Nystagmus (no fixation) | Left-beating, center/left/up | Right peripheral hypofunction |
| Head Shake Nystagmus | Left-beating post-HSN | Right peripheral asymmetry |
| Dix-Hallpike Right | Posterior-beating + torsional nystagmus | Right posterior canal BPPV |
| Multiple positional nystagmus | Multi-positional involvement | Canalith migration / multi-canal |
| SVV | Borderline 3° deviation | Mild otolithic dysfunction |
Diagnosis
Primary Diagnosis:
Benign Paroxysmal Positional Vertigo (BPPV) - Right Posterior Semicircular Canal
- Positional nystagmus on right Dix-Hallpike with posterior-beating torsional component confirms canalith repositioning in the right posterior canal.
Secondary Diagnosis:
Right-sided Peripheral Vestibular Hypofunction (Unilateral)
- Direction-fixed spontaneous nystagmus in darkness (left-beating, ~17 °/s), suppressed by fixation
- Post-head-shake nystagmus beating toward the left
- Gaze nystagmus without fixation predominantly in left/center/up gaze
- SVV mildly tilted
Additional Finding (Possible Central Component):
Impaired Horizontal Smooth Pursuit and Saccadic Dysmetria
- Significantly reduced rightward smooth pursuit gain (0.16 RE)
- Left-eye saccadic hypermetria
- These findings in a 73-year-old may represent age-related central vestibulo-cerebellar changes and warrant further evaluation (MRI brain/posterior fossa) to rule out cerebellar or brainstem lesion.
Recommendations
- Epley Canalith Repositioning Maneuver for the right posterior canal BPPV - first-line treatment.
- MRI Brain (posterior fossa/cerebellum) - to evaluate for central pathology given abnormal smooth pursuit and saccadic hypermetria in this age group.
- Vestibular Rehabilitation Therapy (VRT) - for compensation of peripheral hypofunction and gait/balance improvement.
- Review in 4-6 weeks post-Epley to assess resolution.
- Consider audiometry if not recently done, given age-related hearing risk.
Note: This report is based on VNG data alone and must be correlated with clinical examination findings, audiological assessment, and imaging for a complete diagnosis. The presence of both peripheral and possible central features in a 73-year-old patient warrants thorough neurological evaluation.
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